PATIENT INFORMATION

CARBOHYDRATE COUNTING
AND INSULIN DOSE
ADJUSTMENT
 The Nutrition and Dietetic Department contact numbers:

Worcester Hospital: 01905 760696

Kidderminster and Redditch: 01562 512305

Mobile: 07834172228

Your Dietitian……………………………………………………………….

The insulin dose adjustment is the next step in learning carbohydrate counting.

In the first 2 steps of carbohydrate counting, explained in the previous leaflet, you
would have learned to identify the carbohydrate rich foods and estimate the amount of
carbohydrate in these foods using food labels and Carbohydrate Reference Tables.

Once you know how to estimate the carbs in your meals, it is now time to learn how to
adjust your insulin dose according to the amount of carbs at your meal, which is Step 3
of carbohydrate counting.

Step 3 Calculate the insulin dose

The appropriate insulin dose at your meal is worked out using the carbohydrate
content of your meal in grams divided by your personal insulin to carbohydrate
ratio (ICR).

The ICR specifies the number of grams of carbohydrate that is covered by each unit of
rapid acting insulin. The ICR is different for everyone and may vary depending on the
time of day. These ratios also may change over time when you are growing and going
through puberty.

For example:
Your ICR may be: 1 unit of rapid insulin to 10 grams of carbs (ICR 1:10) or
1 unit of rapid insulin for 15 grams of carbs (ICR 1:15) or
1 unit of rapid insulin for 8 grams of carbs (ICR 1:8)

WAHT-PI-0934 Version 1 Approval Date: 26/03/2021 Review Date: 26/03/2024

Your diabetes team will work out your ICR for you.

Once you are given your ICR, you will use it to calculate how much insulin you need at
a meal depending on the amount of carbohydrate in that meal.

Basically you divide the amount of carbs in grams by the ICR.

Carbohydrate Your Insulin dose for the

content of your ÷ =
carbohydrate
meal in grams insulin to carbohydrate ratio

For example: if you having 60g of carbs and your ICR is 1:10, you divide 60 by 10
which gives you an insulin dose of 6 units.

Use your insulin to carbohydrate ratio to work out how much insulin you need to
take to cover the carbohydrate in your meals or snacks.

Work out insulin dose using insulin to carbohydrate ratio:

e.g. If the ratio is 1:12, how much insulin is needed for 30g of carbohydrate?

e.g. If the ratio is 1:12, how much insulin is needed for 150g of carbohydrate?

INSULIN CALCULATOR

You may want to use the insulin calculator to find (without using an actual calculator)
the dose of insulin you need for different amount of carbs using your ICR.

On the top bar of the table across you find your IRC for that meal and on the bar on
the left hand side find the amount of carbs. To find your insulin dose slide your finger
down the column which has your OCR on the top until the row which has the amount
of carbs.
For example: if your ICR is 1:15 and you have 100g of carbs, the insulin dose is 6.5
units.
WAHT-PI-0934 Version 1 Approval Date: 26/03/2021 Review Date: 26/03/2024
 Insulin to Carbohydrate Ratio

1:35 1:30 1:25 1:20 1:18 1:15 1:12 1:10 1:8 1:7 1:5 1:3
Carbohydrate in grams

10 0 0 0.5 0.5 0.5 0.5 1 1 1 1.5 2 3.5

20 0.5 0.5 1 1 1 1 1.5 2 2.5 3 4 6.5

30 1 1 1.5 1.5 1.5 2 2.5 3 3.5 4 6 10

40 1 1 2 2 2 2.5 3 4 5 5.5 8 13

50 1.5 1.5 2.5 2.5 2.5 3 4 5 6 7 10 16.5

60 1.5 2 3 3 3 4 5 6 7.5 8.5 12 20

70 2 2 3.5 3.5 4 4.5 5.5 7 8.5 10 14 23

80 2 2.5 4 4 4.5 5 6.7 8 10 11.5 16 26.5

90 2.5 3 4.5 4.5 5 6 7.5 9 11 13 18 30

100 3 3 5 5 5.5 6.5 8 10 12.5 14 20 33

110 3 3.5 5.5 5.5 6 7 9 11 13.5 15.5 22 36.5

120 3.5 4 6 6 6.5 8 10 12 15 17 24 40

130 3.5 4 6.5 6.5 7 8.5 10.5 13 16 18.5 26 43.5

140 4 4.5 7 7 7.5 9 11 14 17.5 20 28 46.5

150 4 5 7.5 7.5 8 10 12.5 15 18.5 21.5 30 50

160 4.5 5 8 8 8.5 10.5 13 16 20 23 32 53.5

170 5 5.5 8.5 8.5 9.5 11 14 17 21 24.5 34 56.5

180 5 6 9 9 10 12 15 18 22.5 25.5 36 60

190 5.5 6 9.5 9.5 10.5 12.5 15.5 19 23.5 27 38 63.5

200 5.5 6.5 10 10 11 13 16.5 20 25 28.5 40 66.5

Now have a go at working out your insulin dose for different meals based on your ICR
and the amount of carbs in your meal. Either use the ‘insulin calculator’ on the
previous page or use your calculator to divide the amount of carbs in your meal by
your ratio to find the insulin dose.

WAHT-PI-0934 Version 1 Approval Date: 26/03/2021 Review Date: 26/03/2024

 What is your insulin to carbohydrate ration for breakfast?
How many units of insulin do you need for:
30g carbohydrate:___________________________________________

50g carbohydrate:___________________________________________

100g carbohydrate:______________________________________________

What is your insulin to carbohydrate ration for lunch?

How many units of insulin do you need for:

50g carbohydrate:_________________________________________

80g carbohydrate:_________________________________________

120g carbohydrate:_____________________________________________
_____________________________________________________________
What is your insulin to carbohydrate ration for evening meal?

How many units of insulin do you need for:

60g carbohydrate:____________________________________________

90g carbohydrate:____________________________________________

180g carbohydrate:___________________________________________

WAHT-PI-0934 Version 1 Approval Date: 26/03/2021 Review Date: 26/03/2024

How to work out the correction dose:

The ‘correction’ is used when your blood glucose level is high to work out the amount
of insulin needed to bring your blood glucose to a normal level.

You will use the ‘insulin sensitivity factor’, also called the ‘correction factor’, which
is an estimation of how much 1 unit of rapid acting insulin will lower your blood glucose
level.

This correction factor is specific for each person as it usually depends on the average
daily dose of insulin that the person needs.

Your diabetes team will calculate your ‘correction factor’ and to you how to use
it.

Write your correction factor below:

1 unit of rapid insulin lowers blood glucose by mmol/L

When you know your insulin sensitivity factor, you can work out your
‘correction bolus’, which is the insulin dose you need to lower your blood
glucose to a normal level:

Your target range will normally be 8 mmol/L.

*Remember to check blood ketones if blood glucose is above 14 mmol/l

Example:

Calculate correction bolus if your blood glucose is 16 mmol/l, target blood glucose 8
mmol/L and correction factor is 1:2 mmol/l.

16 mmol/L 8 mmol/L 2 4 units

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Now practice working out the correction bolus:
Pre-meal blood glucose: 18 mmol/L
Target blood glucose: 8 mmol/L
Insulin sensitivity factor: 1 : 5 mmol/L

Guidelines and caution for using correction boluses:

 Check blood glucose 2-3 hours after giving correction bolus

 Do NOT give correction bolus less than your target range

 Do NOT correct if it has been less than 2 hours since your last correction bolus

 If a correction bolus is given between meals, the dose may need to be lower

 Do NOT correct a high blood glucose if you had a hypo in the last 4-6 hours

 If your blood glucose meter has the correction dose programmed in, check your
settings!

Calculate total insulin dose, including insulin for the meal and the correction
dose

To calculate the total mealtime insulin dose you need to work out the amount of insulin
you need for the carbohydrate using your insulin to carbohydrate ratio and if your
blood glucose levels are high then you need to add the correction bolus (correction
dose).

Insulin dose for

the carbohydrate + Correction bolus = Insulin dose
in the meal

WAHT-PI-0934 Version 1 Approval Date: 26/03/2021 Review Date: 26/03/2024

Example:

Work out the insulin bolus for this meal:

Insulin to carbohydrate ratio: 1 unit to 10g CHO
Total amount of carbs in the meal: 30g
CHO bolus: 30g ÷ 10g = 3 units of rapid insulin

Then work out the correction dose:

Pre-meal blood glucose: 14mmolL.
Target blood glucose level: 8mmolL
Insulin sensitivity factor: 1u : 2mmol/L
Correction bolus: (14 – 8) ÷ 2 = 3 units of rapid acting insulin

Now add the insulin bolus for the meal and the ‘correction dose’:
3 units (for food) + 3 units (correction bolus) = 6 units (total insulin dose)

Whenever possible give rapid acting insulin before a meal.

This prevents the large blood glucose spikes between meals.
This will help to decrease your Hba1c!

Consider adjustment for physical activity

Physical activity:

 You may need a snack of 15 to 30 g carbohydrate for every 30 to 60 minutes of

exercise, depending on the exercise intensity.
The duration and intensity of exercise will affect the amount of carbohydrate that
you need.
 If the exercise is more than 30 minutes and it is quite intense, you may need to
reduce the doses of your rapid acting insulin.
 If you are planning to be physically active soon after the meal, you can consider
reducing your insulin dose at that meal, which will give you more energy for the
exercise and you may not need a snack.
 You may need to reduce your rapid acting insulin dose at a meal after the physical
activity to have enough glucose to replenish the muscle stores and prevent a hypo.
 Discuss this further with your Diabetes Team.

WAHT-PI-0934 Version 1 Approval Date: 26/03/2021 Review Date: 26/03/2024

 Adjust insulin doses

When you have learned carbohydrate counting and you are able to adjust insulin
doses according to your blood glucose levels, it is important to also learn to adjust
the ICR to get accurate insulin doses and keep blood glucose levels in range.

In order to adjust insulin doses, you need to know which insulin has an effect on
your blood glucose at what time. Have a look at this table:

Insulin time Effects blood glucose

Evening: background insulin Overnight and before breakfast

(Lantus/Levemir)

Breakfast: rapid acting 2 hours after breakfast and

(Novorapid/Humalog/Apidra) before lunch

Lunch: rapid acting 2 hours after lunch and before

(Novorapid/Humalog/Apidra) evening meal

Evening meal: rapid acting 2 hours after evening meal and

(Novorapid/Humalog/Apidra) before bed

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Adjusting the ICR according to blood glucose levels:

Your diabetes team will help you with adjusting the ICR initially, but in long term it
would be good for you to know how to do that by yourself, or at least to know when
you need to highlight to your diabetes team that you think your ratios need to be
altered.

 To test if your ICR is well adjusted you will need to choose a day when your
blood glucose level is below 10 mmol/l, no hypos in the previous 12 hours and no
strenuous physical activity on that day.
 For testing your ICR choose meals that are balanced if possible, meaning that
the meal has a moderate amount of carbs, some vegetables and is not too high
in fat.
 You need to carb count as accurately as you can and then calculate your insulin
dose using your current ICR.
 Check your blood glucose before the meal. You can test your ratio when your
blood glucose if anywhere between 4 to 10 mmol/l. Do not give a correction
dose, just the insulin to cover the carbohydrate. If your blood glucose is above
10 mmol/l you would not be able to test you ICR at that meal, as you would need
to give a correction, therefore the ICR test would not be accurate.
 You then need to test your blood glucose about 4 hours later, without having any
carbs inbetween.
 If your blood glucose is within 2 mmol/l to what it was before the meal, it means
your ICR is well adjusted.
 If there is more than 2 mmol/l difference between blood glucose before the meal
and 4 hours later, it means that you probable need to adjust the ICR. To be sure
that the ICR needs adjusting, it would be advisable to repeat the ICR test once or
twice before making any changes.

WAHT-PI-0934 Version 1 Approval Date: 26/03/2021 Review Date: 26/03/2024

Adjusting the insulin to carbohydrate ratios:

Over time the amount of carbohydrate you need for each unit of insulin may change.

You can adjust your ratios for each meal by looking at patterns in your blood glucose
levels.

Use this scale to find out which way.

Move this way if Insulin to carbohydrate

How to test that your insulin
blood glucose ratio to carb ratio is fine:
levels are too 1 unit to 3g  Test your blood glucose
high before a meal
1 unit to 5g You should not have given
any insulin boluses during
1 unit to 6g
the previous 4 hours before
1 unit to 7g this meal
 Make sure you counted the
1 unit to 8g
carbs correctly
1 unit to 9g  Give your usual insulin to
carb bolus
1 unit to 10g (½ unit to 5g)  Check your blood glucose 4
hours after your meal
1 unit to 12g (½ unit to 6g)
 Your blood glucose 4 hours
1 unit to 14g (½ unit to 7g) after the meal should be
within the target level
Move this way if 1 unit to 16g (½ unit to 8g)  If the blood glucose 4 hours
blood glucose after the meal is out of
levels are too 1 unit to 18g (½ unit to 9g) target, review your insulin to
low 1 unit to 20g (½ unit to 10g)
carb ratio
 If at any stage during the
1 unit to 25g (½ unit to 12.5g) test you have a hypo, stop
the test, treat the hypo and
1 unit to 30g (½ unit to 15g) repeat the test on another
occasion
1 unit to 35g (½ unit to 17.5g)

1 unit to 40g (½ unit to 20g)

Your diabetes team will help you to calculate your insulin to carbohydrate ratio
and will show you how to adjust it according to your blood glucose levels

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If your symptoms or condition worsens, or if you are concerned about anything,
please call your GP, 111, or 999.

Patient Experience
We know that being admitted to hospital can be a difficult and unsettling time for you
and your loved ones. If you have any questions or concerns, please do speak with a
member of staff on the ward or in the relevant department who will do their best to
answer your questions and reassure you.
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If you have any concerns or questions about your care, we advise you to talk with the
nurse in charge or the department manager in the first instance as they are best
placed to answer any questions or resolve concerns quickly. If the relevant member of
staff is unable to help resolve your concern, you can contact the PALS Team. We offer
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Our PALS team will liaise with the various departments in our hospitals on your behalf,
if you feel unable to do so, to resolve your problems and where appropriate refer to
outside help.
If you are still unhappy you can contact the Complaints Department, who can
investigate your concerns. You can make a complaint orally, electronically or in writing
and we can advise and guide you through the complaints procedure.
How to contact PALS:
Telephone Patient Services: 0300 123 1732 or via email at: wah-tr.PET@nhs.net
Opening times:
The PALS telephone lines are open Monday to Thursday from 8.30am to 4.30pm and
Friday: 8.30am to 4.00pm. Please be aware that a voicemail service is in use at busy
times, but messages will be returned as quickly as possible.
If you are unable to understand this leaflet, please communicate with a member of
staff.

WAHT-PI-0934 Version 1 Approval Date: 26/03/2021 Review Date: 26/03/2024